ARTICLE IN PRESS

Acute Stroke Care in the Coronavirus Disease 2019 Pandemic

Rima M. Dafer, MD, MPH,* Nicholas D. Osteraas, MD, MS,* and Jose Biller, MD†

Coronavirus disease 2019 (COVID-19) is a pandemic respiratory disease with serious

public health risk and has taken the world off-guard with its rapid spread. As the
COVID-19 pandemic intensifies, overwhelming the healthcare system and the medi-
cal community, current practice for the management of acute ischemic stroke (AIS)
will require modification, and guidelines should be relaxed while maintaining high
standard quality of care. The aim of these suggestions is to avoid contributing to the
rapid spread of COVID-19 as well as to conserve what are likely to be very limited
resources (including personnel, intensive care/hospital beds as well as physicians)
while maintaining high quality care for patients with AIS. We present our recommen-
dations for the management of acute stroke during the COVID-19 pandemics.
Keywords: COVID-19—Coronavirus—Ischemic stroke—Stroke management—
Editorial
© 2020 Elsevier Inc. All rights reserved.

Introduction
The first cases of coronavirus disease (COVID-19) were
reported in December of 2019 in Wuhan, China, and rapidly
pendahuluan
spread to the rest of the world.1,2 In February of 2020, Italy
disease control (CDC), global mortality for the novel virus
is 3.4%, with around 80% of deaths occurring among
masukkin
adults 65 years and older with the highest percentage of
severe outcomes occurring in people over 85 years of age.

became the European country with highest total case count

ke epid
Patients with underlying medical problems common in
the stroke population including heart disease, chronic
with an exponential increase in the number of cases and in
lung disorders, diabetes, and the immunocompromised
mortality, predominantly in the Lombardy area. As the dis-
are more likely to develop serious illness.6
ease spread worldwide, it was declared a pandemic on
As of April 21st, 2020, global cases had passed 2.5 mil-
March 11, 2020 by the World Health Organization (WHO)1,2
lion, with more than 175,000 deaths worldwide. The
and the United States has taken the lead in new daily cases.3
United States continues to have the most confirmed cases
Typical symptoms of COVID-19 include high grade
worldwide, with over 820,000 cases and 45,000 deaths.3
fever, dry cough, shortness of breath, fatigue, dysgeusia,
and anosmia.4 While many infected subjects may be masukkin gejala klinisThese numbers will only continue to increase by the time
of press release. The continuous rise in cases of COVID-19
asymptomatic or have mild symptoms,5 the disease can
with the associated demand for medical attention has
rapidly progress to a serious illness in up to 16% of
caused a major burden on health care systems, with
infected subjects, affecting the lungs and causing severe
increases in health care utilization beyond current hospital
acute respiratory distress syndrome, respiratory failure,
capacities. This extends to increase bed occupancy, short-
and death.4 Given that vascular endothelial cells express
age of intensive care beds, and extensive need for expan-
receptors for COVID-19, vascular complications can occur
sion of workforce and allocation of limited resources.
as a result of infection as well.6 According to the center for
Vascular neurologists need to remain vigilant as
majority of stroke patients are older and have underlying
medical conditions associated not only with risk for
From the *Rush University Medical Center, United States of Amer-
ica; and †Loyola University Medical Center, United States of America. ischemic stroke, but poor outcomes associated with
Received April 5, 2020; revision received April 8, 2020; accepted COVID-19 as well.6,7 We believe that it is crucial for the
April 8, 2020. stroke community to relax guidelines and stroke path-
The authors have no disclosures. There was no grant support. ways while continuously providing high quality of care,
Address correspondence to Nicholas D. Osteraas, MD, MS, 1725 W
including treatment algorithms, post intravenous throm-
Harrison street Suite 1118, Chicago IL, 60612, United States of Amer-
ica. E-mails: Rima_M_Dafer@Rush.edu, bolysis monitoring, diagnostic work up, disposition
Nicholas_D_osteraas@rush.edu. planning, prevention measures, in order to optimally
1052-3057/$ - see front matter care for stroke patients while minimizing the chances of
© 2020 Elsevier Inc. All rights reserved. contributing to the rapid spread of COVID-19.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104881

Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104881 1
 ARTICLE IN PRESS
2 R.M. DAFER ET AL.
These suggestions apply not only to individual hospi-
tals, but larger systems as well. Stroke care often involves
large networks of hospitals; commonly with a comprehen-
sive “hub” and multiple spoke sites, which identify, start
appropriate treatment and transfer stroke patients to the
hub of the spoke for continued stroke care. Given the eco-
nomics of the healthcare system in the United States, large
metropolitan cities frequently have separate hub and
spoke systems that overlap geographically with each
other to a significant extent. It is a real possibility that one
or more of these hub an d spoke systems may become
overwhelmed with COVID-19 patients, thus it is impor-
tant for hospital leadership to re-examine existing rela-
tionships to allow for smooth reallocation of resources,
mobilizing workforce, optimizing new beds availability,
and rapidly liberating ICU beds.
We present our recommendations for the management
of acute stroke during the COVID-19 pandemic, in a chro-
nologic fashion following care from the pre-hospitaliza-
tion stage to rehabilitation; with the goal of adapting care
without sacrificing quality despite potentially limited
resources as suggested by Emanuel et al.8
Prehospitalization
Stroke remains a medical emergency requiring ordinary
urgent care even in the midst of the COVID-19 outbreak.
Patients should continue to call 911 for symptoms suspi-
cious for stroke. In addition to standard triage, the emer-
gency medical system (EMS) personnel should screen
over the phone for COVID-19 symptoms. Patients with
low suspicion for stroke, or mild symptoms with no
potential indication for acute intervention may be evalu-
ated via telemedicine (when possible) to aid in determina-
tion if immediate hospitalization is necessary. Given the
degree of community spread of COVID-19, along with
cases of asymptomatic transmission, all patient with acute
stroke symptoms should be treated as suspected or possi-
ble COVID-19 patients (frequently termed person under
investigation, PUI), and all personnel physically in contact
should wear appropriate personal protective equipment
(PPE). Of note, several centers in Chicago have seen a
decline in stroke admissions and EMS calls for stroke are
down by twenty percent. If this is a result of social dis-
tancing practices reducing the frequency of which patients
with stroke are found, or from fear on behalf of patients of
contracting COVID-19 by seeking out care is unclear.
Emergency Room Evaluation
In the emergency room, patients should be screened for
COVID-19 prior to evaluation by the stroke team. Given
the emergent nature of stroke care, difficulty in obtaining
in many cases a complete review of systems and contact
history, tele-stroke evaluation could be conducted in cen-
ters that have this capability. It is preferable that all
patient be given a mask to secure protection of the in
person treating team. Appropriate personal protective
equipment (PPE) should be used according to the CDC
and local institution guidelines, (a so called ‘protected
stroke code,’9) along with treatment in designated loca-
tion separate than the rest of the patients. All patients
should receive the standard of stroke care and should be
evaluated for potential thrombolysis with intravenous tis-
sue plasminogen activator (rtPA) or tenecteplase (TNK),
along with endovascular thrombectomy (ET) when large
vessel occlusion (LVO) is suspected. It may be possible in
select cases (such as a transient ischemic attack and small
lacunar infarct with minimal deficits) to obtain expedited
testing and critical evaluations in the emergency room,
sparing a hospital admission.10
Hospitalization
As the hospitals progress to becoming crowded out by
the influx of COVID-19 patients, and as units are being
converted to accommodate and treat infected patients, dis-
tribution of beds in separate isolated units should be
planned in advance. Patients receiving intravenous chemi-
cal thrombolysis should be monitored per current stroke
guidelines; however, to avoid unessisary exposure of per-
sonnel, monitoring could be performed virtually with two-
way video conferencing in some cases. In the event that
resources are so strained that standard protocol cannot be
effectively adhered to, a difficult decision would have to be
made to either with-hold thrombolysis, or utilize an abbre-
viated protocol for post thrombolysis monitoring.11 As
mentioned by a recent AHA position paper, treatment for
eligible patients should continue to be offered, even if every
vital sign assessment cannot occur at the prescribed time
interval.12 Current practices involve institutions admitting
post thrombolysis patient to intensive care units (ICU); to
avoid utilization of ICU beds, stroke patients post throm-
bolysis may be admitted to intermediate care unit (IMCU)
manajemen
or stroke ‘step down’ units, supervised by neurologists or
vascular neurologists presuming there is a low probability
of intensive care unit needs12,13 along with early acceptance
of patients with small, stable intracerebral hemorrhages
and those with subarachnoid hemorrhage at low risk for
vasospasm as suggested by Chartrain and colleagues.14
Patients with large strokes and otherwise requiring close
intensive care monitoring for high risk of hemorrhagic trans-
formation, intubation, stent re-occlusion or other critical care
needs may be admitted to ICU in a designated COVID-19
rule out part of these units. This would ideally occur under
the supervision of an intensivist as a primary attending,
with the vascular neurologist rounding remotely or with
daily telephone-based discussion on management and treat-
ment plans to minimize both PPE use as well as opportuni-
ties for inadvertent viral transmission. Early transfer to
IMCU or stroke unit should be initiated when the patient is
deemed stable to liberate ICU beds. In centers that do not
have IMUC beds, it may be possible to work with hospital
 ARTICLE IN PRESS
ACUTE STROKE CARE IN THE CORONAVIRUS DISEASE 2019 PANDEMIC
administration, physicians and nursing to designate floor
beds as such, to allow for less critically ill patients to move
out of intensive care units if needed.15
Diagnostic testing should be consolidated when possible
and should only be ordered if deemed necessary to initiate
appropriate management. For example, in patients with sub-
cortical infarctions suspected to be due to small vessel disease,
sonographic studies should be limited or even avoided to
minimize exposure to technicians, especially as ultrasound
machines may need to be cleaned between patients. A patient
with possible intracranial or extracranial atheromatous dis-
ease as an ischemic stroke etiology could have one test with a
CT angiogram (CTA) of both the head and neck, as opposed
to separate machine and technician utilization with both an
MR angiogram (MRA) or CTA of the head with ultrasound
imaging of the carotids. For the most part, assuming low sus-
picion for endocarditis or cardiac thrombus, echocardio-
graphic studies may be arranged and obtained as outpatient
assuming an outpatient imaging center nearby is in operation.
Telemedicine should be used when possible during
rounds with residents and fellows to minimize exposure
of healthcare personnel, especially if COVID-19 infection
is suspected or confirmed. Additionally, telemedicine
may be utilized should the physicians test positive for the
virus. Physicians who remain medically stable only mild
(or absence of any) symptoms can continue to evaluate
and treat patients remotely via telemedicine.
Rehabilitation Planning
All healthcare workers caring for patients with COVID-19
are at elevated risk of exposure and should wear appropriate
protective gears. Physical therapy (PT), occupational therapy
(OT), speech therapy (ST), along with rehabilitation services
are frequently involved in the care of stroke patients, and are
an integral part of stroke recovery.16 Additional care should
be in place when consulting such services as opposed to
involving all therapy services indiscriminately, and therapy
services (when appropriate) should also emphasize teaching
safe rehabilitative exercises that can be done by the patient ‘as
homework’ when alone. In a similar vein, the majority of the
important work done by dietary consultants, pharmacists
and stroke education nurses regarding risk factor modifica-
tion could potentially be done without direct patient contact
in many cases.17
Family Members
While obtaining history and medical information from
family members is frequently necessary, especially when
patients are aphasic or have mental status changes, many
hospitals have appropriately restricted visitors or have insti-
tuted no visitor policy. Extra effort will need to be made to
reach out to families by phone to discuss a patient’s history,
condition, treatment options, and discharge planning with
family members and caregivers. Exceptions to the visitor
3
policy, such as discussions regarding end of life care, should
be made when appropriate.
Transfers
Stroke care often involves networks of hospitals; com-
monly a comprehensive “hub” with multiple smaller hos-
pitals or “spoke” sites which transfer stroke patients to
the hub of the spoke for care for higher level of care such
as ET, or ICU care for massive infarcts with cerebral
edema or for intracerebral hemorrhage (ICH). Tele-stroke
should be encouraged to evaluate patients and to prevent
unnecessary transfers. For acute ischemic stroke, neuroim-
aging including arterial imaging should be obtained at the
spoke site, and should be reviewed both by local radiolog-
ists as well as the tele-stroke physician to aid in appropri-
ate patient selection for transfer.
The tele-stroke physicians may be required to make
sobering decisions over when to utilize limited resources
and risk COVID-19 spread when considering a potential
transfer. For example, physician may choose not to
accept a transfer of patients with massive hemorrhages,
or patients with ischemic stroke who have very low like-
lihood of a good outcome post stroke treatment.
When transfer is deemed necessary, patients should be
screened for COVID-19 at the spoke site. If clinical suspicion
of COVID-19 infection is high, the hub interventional team
should be prepared using appropriate PPE, with N95 respi-
rators to protect from airborne particles and from liquid con-
tamination during the endovascular procedure in the event
that intubation is required. Otherwise, a surgical mask may
be sufficient. Post intervention, patients should be admitted
to the appropriate ICU units as discussed above.
Elective Surgeries
Many institutions both nationwide and worldwide
have postponed non-urgent surgical procedures for
weeks (e.g., elective carotid or cardiac surgery) and urgent
surgical intervention will take precedent. Non-urgent pro-
cedures are still being performed in some selected centers.
Discharge Planning
Many patients surviving the initial stroke are left
with disabilities requiring intensive physical therapies
in inpatient rehabilitation facilities. While early and
intense rehabilitation is critical in stroke recovery, 16
discharges to acute rehabilitation institutions and long
term facilities have been delayed due to concerns
about the spread of COVID-19 infections in long term
care facilities and nursing homes, particularly in some
parts of the US. The Seattle-based Life Care Center of
Kirkland nursing home in Kirkland, Washington was
considered “ground zero” in the COVID-19 pandemic
by the CDC director. Case work managers and dis-
charge planners will continue to work with admission
 ARTICLE IN PRESS
4 R.M. DAFER ET AL.
teams at the inpatient rehabilitation centers to expedite
discharges. Ideally there would be no change in post
hospitalization placement in acute and subacute reha-
bilitation facilities; realistically, however, hospitals
may need to designate rehabilitation beds for patients
who do not qualify for transfer to acute inpatient facili-
ties, as well as discuss discharging patients home when
medically stable and appropriate until the pandemic is
under control if there is no practical placement option.
Establishing Stroke Networks
Lastly, establishing stroke networks within cities and col-
laboration between institutions should be seriously consid-
ered as the surge of COVID-19 worsens. The COVID-19
pandemic should be considered a war against humankind,
and emergency planning should be encouraged by institu-
tional authorities. It is not long until transfer of COVID-19
patients between facilities will be necessary as institutions
become overwhelmed with the surge of patients. The
stroke community should encourage collaborations among
stroke networks to establish a rotating weekly coverage for
acute stroke care in a specified geographic area; thus both
freeing hospital resources and releasing stroke call respon-
sibilities and allowing those physicians to help in caring for
patients on the COVID-19 units.
Conclusion
In summary, with the significant impact of the COVID-
19 pandemic on the healthcare system and the rapid
depletion of its resources, urgent steps should be taken
while managing acute stroke patients to prevent the
spread of the disease, to protect both patients and staff,
and to minimize the uses of already strained resources.
References
1. Bedford J, Enria D, Giesecke J, et al. COVID-19: towards
controlling of a pandemic. Lancet 2020;395:1015-1018.
2. Wu Z, McGoogan JM. Characteristics of and important
lessons from the coronavirus disease 2019 (COVID-19)
outbreak in China: summary of a report of 72314 cases
from the Chinese Center for Disease Control and Preven-
tion. JAMA 2020;323:1239-1242.
3. Dong E, Du H, Gardner L. An interactive web-based
dashboard to track COVID-19 in real time. Lancet Infect
Dis 2020. [ahead of print].
4. Zu ZE, Jiang MD, Xu PP. Coronavirus disease 2019
(COVID-19): a perspective from China. Radiology
2020:200490.
5. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier
transmission of COVID-19. JAMA 2020;323:1406-1407.
6. Zhou F, Yu T, Du R, et al. Clinical course and risk factors
for mortality of adult inpatients with COVID-19 in
Wuhan, China: a retrospective cohort study. Lancet
2020;395:1054-1062.
7. Li Y, Wang M, Zhou Y, et al. Acute cerebrovascular dis-
ease following COVID-19: a single center, retrospective,
observational study. Lancet 2020.
8. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of
scarce medical resources in the time of Covid-19. N Engl J
Med 2020.
9. Khosravani H, Rajendram P, Notario L, et al. Protected
code stroke: hyperacute stroke management during the
coronavirus disease 2019 (COVID-19) pandemic. Stroke
2020. [ahead of print].
10. Majidi S, Leon Guerrero CR, Burger KM, et al. Inpatient
versus outpatient management of TIA or minor stroke:
clinical outcome. J Vasc Interv Neurol 2017;9:49-53.
11. Faigle R, Butler J, Carhuapoma JR, et al. Safety trial of
low-intensity monitoring after thrombolysis: optimal
post Tpa-Iv monitoring in ischemic STroke (OPTIMIST).
Neurohospitalist 2020;10:11-15.
12. Temporary emergency guidance to US stroke centers during
the COVID-19 pandemic. Stroke 2020. [ahead of print].
13. Faigle R, Marsh EB, Llinas RH, et al. ICAT: a simple score
predicting critical care needs after thrombolysis in stroke
patients. Crit Care 2016;20:26.
14. Chartrain AG, Awad AJ, Sarkiss CA, et al. A step-down
unit transfer protocol for low-risk aneurysmal subarach-
noid hemorrhage. Neurosurg Focus 2017;43:E15.
15. Plate JDJ, Leenen LPH, Houwert M, et al. Utilisation of
intermediate care units: a systematic review. Crit Care
Res Pract 2017;2017:8038460.
16. Coleman ER, Moudgal R, Lang K, et al. Early rehabilita-
tion after stroke: a narrative review. Curr Atheroscler
Rep 2017;19:59.
17. McBride CM, Rimer BK. Using the telephone to improve
health behavior and health service delivery. Patient Educ
Couns 1999;37:3-18.